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Urinary Incontinence and Depression in Middle-Aged United States Women

From the Departments of Obstetrics and Gynecology and Psychiatry, University of Iowa College of Medicine; and Departments of Biostatistics and Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa.

	ABSTRACT

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OBJECTIVE: To determine the correlates of incontinence in middle-aged women and to test for an association between incontinence and depression.

METHODS: This was a population-based cross-sectional study of 5701 women who were residents of the United States, aged 50–69 years, and participated in the third interview of the Health and Retirement Study. The primary outcome measure was self-reported urinary incontinence. Depression was ascertained based on criteria set by the Diagnostic and Statistical Manual of Mental Disorders, using a short form of the Composite International Diagnostic Interview. In addition, depressive symptoms were assessed using the revised Center for Epidemiologic Studies Depression Scale. Multivariable logistic regression models were constructed to determine the independent association between incontinence and depression, after adjusting for confounders.

RESULTS: Approximately 16% reported either mild-moderate or severe incontinence. Depression, race, age, body mass index, medical comorbidities, and limited activities of daily living were associated with incontinence. After adjusting for medical morbidity, functional status, and demographic variables, women with severe and mild-moderate incontinence were 80% (odds ratio [OR] 1.82; 95% confidence interval [CI] 1.26, 2.63) and 40% (OR 1.41; 95% CI 1.06, 1.87) more likely, respectively, to have depression than continent women. The association did not hold for depressive symptoms measured by the revised Center for Epidemiologic Studies Depression Scale after adjusting for covariates.

CONCLUSION: Depression and incontinence are associated in middle-aged women. The strength of the association depends on the instrument used to classify depression. This reinforces the need to screen patients presenting for treatment of urinary incontinence for depression.

Urinary incontinence is a common problem in older women, with prevalence estimates ranging from 10% to 80%. Severe incontinence is reported more consistently in 3–10% of women.¹ Some risk factors for urinary incontinence are well known, whereas others remain speculative. Most epidemiological studies have shown a consistent association between urinary incontinence and increasing age,^2–5 childbirth,^6–9 obesity,^10–13 dementia,¹⁴ functional impairment,^15,16 and certain medical comorbidities, particularly diabetes¹⁷ and stroke.¹⁸ The association between incontinence and other factors is less clear. There is conflicting information about the potential roles of menopause,¹⁹ hysterectomy,^20,21 constipation,^22–24 and cigarette smoking^25,26 in the development or exacerbation of incontinence. Correlates of incontinence differ by age group.²⁷

Psychologic distress and measures of depressive symptoms have also been inconsistently linked to urinary incontinence in small clinic-based studies^28–32 and in a larger community study of older adults.³³ Two larger population-based studies found associations between depressive symptoms and "difficulty holding urine"²⁷ and between incontinence status and psychologic distress in women.³⁴ Most research to date has focused on the elderly. Epidemiological study of the elderly is distinguished from that in middle-aged adults by the greater complexity of characterizing health status in older age.³⁵ The elderly are more likely to have chronic conditions, as well as increasing numbers of age-related physiologic changes and dysfunctions. It then becomes more difficult to disentangle the causes and outcomes of health conditions. For example, physical mobility limitations could contribute to both depression and incontinence. By examining this issue in a population of middle-aged rather than elderly women, we may improve our ability to characterize the association between incontinence and depression.

The aim of this study is to assess the relation between urinary incontinence and depression in a large population-based cross-sectional study of women aged 50–69 years. To improve upon methods used in prior studies, depression is defined both by a diagnosis based on criteria set by the Diagnostic and Statistical Manual of Mental Disorders and by a commonly used continuous measure of depressive symptoms. In addition, correlates of urinary incontinence are examined separately for mild-moderate and severe incontinence.

	MATERIALS AND METHODS

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The study population is drawn from participants in the Health and Retirement Survey, a large prospective population-based study³⁶ funded by the National Institute of Aging and coordinated by the Institute for Social Research at the University of Michigan. The Health and Retirement Survey was designed to provide in-depth information about health, economic, and sociological issues surrounding retirement. At inception, target subjects ranged in age from 51 to 61 years; spouses of any age were also interviewed. All respondents provided oral informed consent, and internal ethics review board approval was obtained. To identify age-eligible persons, the Health and Retirement Survey screened approximately 70,000 households obtained from an area probability sample.³⁷ Blacks and Hispanics were over-sampled at a rate of 2:1 relative to whites. Residents of Florida were also over-sampled. The overall baseline response rate was 82%. Comparing respondents with the 1990 US Census data indicated no sample bias.³⁸ The baseline proxy (ie, response by someone other than the participant, generally because the participant is unable to respond herself) response rate was 5%. Subjects have undergone interviews at approximately 2-year intervals since 1991. Information collected at the third interview (1995 to 1996) was used for the present study, because of the more specific incontinence questions used for that interview (or wave). For wave 3, respondents were interviewed by telephone. Men and subjects institutionalized or interviewed through a proxy were excluded from this analysis. Because spouses of any age were included in the study, the original wave 3 sample included a wide age range, from 25.8 to 76.6 years. As the focus of this study was to assess urinary incontinence in upper middle–aged women, the age range was narrowed to 50–69 years.

In waves 1 and 2, only a general question about "bladder problems" was included. However, in subsequent waves that question was changed to "In the last 12 months, have you lost any amount of urine beyond your control?" Those who responded positively were asked about the frequency of leakage. The dependent variable, urinary incontinence, was classified into three levels: 1) continent, in which women responded negatively to the screening question; 2) mild-moderate incontinence, in which women responded affirmatively to the screening question and reported incontinence on 15 or fewer days in the last month; and 3) severe incontinence, in which women reported incontinence on more than 15 days in the last month. For ease of reporting, the mild-moderate category will henceforth be called mild incontinence.

Depression was a focus of all waves. Wave 3 contained an eight-item version of the Center for Epidemiologic Studies Depression Scale, which is a symptom inventory, and the short form of the Composite International Diagnostic Interview, which is used to diagnose depression. The time frames differ between the two measures of depression. The Center for Epidemiologic Studies Depression Scale queries how respondents have been feeling the week before the interview, whereas the Composite International Diagnostic Interview assesses whether respondents have had any 2-week periods in the past year in which the key symptoms were experienced more often than not. We categorized depressive symptoms as present using the revised Center for Epidemiologic Studies Depression Scale if the subject endorsed six or more of the eight items. This cut point was based on the established cut point of 16 or more on the full scale.³⁹ The short version of the original Composite International Diagnostic Interview⁴⁰ includes eight of the nine possible associated symptoms required for making the diagnosis of depression by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. The diagnosis of depression, also used for our study, requires 1) the presence of depressed mood or anhedonia, for most of each day for most of a 2-week period of time, and 2) the presence of at least four other symptoms on the scale.

All waves collected the following self-reported covariates: age, medical conditions, weight, exercise, functional level, ethnicity, disability, and education. Demographic data were categorized as noted in Table 1. The following comorbidities were assessed through self-report: hypertension, diabetes, cancer, lung disease, myocardial infarction, angina, congestive heart failure, stroke, and arthritis. The prevalence of urinary incontinence was significantly associated with the presence of each disease (all with P < .001), from univariate analysis using the ² test. Because of colinearity between various disease groups, a comorbidity index was created based on the association between incontinence prevalence and the number of comorbidities present. There was a linear increase in both mild and severe incontinence when the number of comorbidities was categorized in the following manner: zero, one to two, three to five, six or greater. This categorization was thus used in the logistic analysis.

Functional limitations were assessed in the Health and Retirement Survey with a group of 11 questions designed to assess more minor degrees of functional loss than typical activity of daily living scales. Based on increases in incontinence at varying levels of limitations, functional limitations were categorized as none, one or two limitations, and three or more limitations. Another group of six activities of daily living questions ascertained more severe limitations and included them in the following activities: walking across the room, dressing, bathing, eating, getting in or out of bed, or using the toilet. There was a sharp rise in incontinence if a woman had a single limitation. This variable was dichotomized. Medication use for psychiatric illness was considered to be present if the respondent answered affirmatively to the question "Do you now take tranquilizers, antidepressants, or pills for nerves?" and otherwise was negative.

Because risk factors may differ between mild and severe incontinence, for analysis, each of these groups was compared with the group with no incontinence. Two separate logistic regression models (one for severe and one for mild incontinence) were determined, and women with no incontinence served as the reference group.

The initial analyses included a description of the population. Univariate analyses (using ² tests, independent t test, or analysis of variance) were conducted to investigate the association of each covariate with urinary incontinence. Linearity of the relationship between covariates and the dependent variable was assessed and appropriate categories were created. Those variables associated with incontinence on univariate analysis (P < .10) were included in multivariable logistic regression analysis models. Because the two depression scales may measure different aspects of depression, separate models were constructed using either the Center for Epidemiologic Studies Depression Scale or the Composite International Diagnostic Interview. To determine whether treatment for psychiatric illness modified the effect of depression on incontinence, as hypothesized, an interaction term was added (treatment * depression) to each final model. Other biologically plausible interactions, as determined by literature review, were also evaluated, one at a time, in each final model. Significant interaction terms were retained in the final model. Model fit was evaluated using the Hosmer-Lemeshow goodness-of-fit statistic. All analyses were accomplished using procedures from the Statistical Analysis System 8 (SAS Institute Inc., Cary, NC).

	RESULTS

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There were 5701 women in this sample. Nine hundred five women (15.9%) reported incontinence and 4796 did not. Of the total, 249 (4.4%) had severe incontinence, whereas 591 (10.5%) had mild-moderate incontinence. Sixty-five women did not respond to the frequency of incontinence question and could not be categorized. These 65 women are not included in subsequent logistic regression analyses.

Approximately one in ten women (9.8%) endorsed six or more symptoms on the revised Center for Epidemiologic Studies Depression Scale. Similarly, 9.4% met criteria for depression according to the short-form Composite International Diagnostic Interview. Although there was some overlap between ratifying both criteria, only 3.8% were categorized as depressed using both scales; 4.1% of women were taking a medication for psychiatric illness at the time of the interview. Demographic characteristics and health variables of the group are shown in Table 1.

Depression as assessed by both the short-form Composite International Diagnostic Interview and the revised Center for Epidemiologic Studies Depression Scale was significantly associated with severe incontinence on univariate analysis. An increased risk of severe incontinence on univariate analysis was also noted with increasing age, parity, BMI, taking a medication for psychiatric illness, smoking, and increases in the comorbidity index, activities of daily living index, and functional limitations. Black and Hispanic women were less likely to report severe incontinence than white women, as were women with lower education and women who reported regular strenuous exercise.

On univariate analysis of risk factors for mild incontinence, associations were similar to those for severe incontinence, with a few exceptions: Parity, smoking, and education were not significantly associated with mild urinary incontinence.

Depression continued to be associated with both mild and severe urinary incontinence in the final multivariable models, but only in the models using the short-form Composite International Diagnostic Interview depression measure. The association did not hold after adjusting for confounders in the models that included the revised Center for Epidemiologic Studies Depression Scale measure. Results from the four final multivariable models are shown in Table 2.

View larger version (27K): [in this window] [in a new window]   Figure 1. Modification of effect of activity of daily living limitation on severe incontinence by age (odds ratio depicts risk for women with at least one activity of daily living limitation relative to women with no activity of daily living limitations). CIDI = Composite International Diagnostic Interview; CES-D = Center for Epidemiologic Studies Depression Scale. Nygaard. Depression and Incontinence. Obstet Gynecol 2003.

	DISCUSSION

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES

 
Using data from a large population-based survey, we found that depression (assessed by the Diagnostic and Statistical Manual of Mental Disorders–based depression tool) was significantly associated with the prevalence of urinary incontinence. After adjusting for covariates, women with severe incontinence were 80% more likely to be depressed, whereas for women with mild incontinence, the risk of depression was 40% higher than for women without incontinence. However, the association did not hold for depressive symptoms, once comorbid medical illnesses and demographic variables were controlled.

The Center for Epidemiologic Studies Depression Scale, at least in this shortened version, is influenced by medical comorbidity and may not be the best measure of depression in studies of incontinence. In contrast, the short-form Composite International Diagnostic Interview, which requires that one endorse either depressed mood or anhedonia before the somatic symptoms of depression such as low energy and poor appetite are assessed, may help discriminate between those with somatic symptoms due to medical illness and those whose symptoms reflect the diagnosis of depression. The contradictory results in the two depression measures may also be related to the time frame that the subjects are asked to recall; subjects recall symptoms occurring the week before the interview for the Center for Epidemiologic Studies Depression Scale, whereas for the Composite International Diagnostic Interview subjects are asked whether they had any 2-week periods in the past year in which the key symptoms were experienced more often than not.

The cross-sectional nature of our study sheds no light on the obvious question of whether being incontinent causes women to be depressed, or whether depression itself causes incontinence. It is possible that both depression and incontinence may share a common hormonal, biochemical, or neurological pathway, given recent evidence that serotonergic pathways are linked to both clinical depression and the regulation of voiding function.^41,42 It is also possible that depressed women are more likely to report incontinence than nondepressed women. In addition, incontinent women may have smaller social networks and fewer outside activities, which in turn may contribute to depression.

Although there was some overlap between risk factors for mild and severe incontinence, several differences were evident. The magnitude of the effect of most variables, including depression, BMI, comorbidity index, and limitations in functional status, was greater for the severe incontinence group. Black and Hispanic women had a decreased risk of both severe and mild incontinence. This mirrors the findings from several other recent studies.^17,43 Early research suggests that this may be because black women have higher urethral closure pressure and larger urethral volume.⁴⁴ Higher level of education was associated with mild but not with severe incontinence. This may reflect the fact that women with higher education are more likely to report mild incontinence. It is unlikely that education is an actual risk factor for incontinence.

Limitations in activities of daily living were an independent risk factor for mild incontinence, increasing the risk approximately 40%. Age, however, was slightly protective for mild incontinence. Others have found a decrease in stress incontinence in older women, likely related to decreased physical activity. Women with urge incontinence are more likely to have severe incontinence. Although we are unable to differentiate incontinence types in this study, these facts may account for the decreased risk of mild incontinence with age. For women with severe incontinence, age modified the effect of activities of daily living limitations on incontinence. The association between BMI and incontinence identified in other studies was also seen in this study. This association is not confounded by other factors (such as parity, functional category, or age). There was no interaction noted between BMI and functional status or comorbidity index. Increased BMI is more highly associated with severe than with mild incontinence. However, given the larger number of women with mild incontinence, the attributable risk of obesity is higher for mild incontinence.

Parity was associated with severe but not mild incontinence. Other studies have found varying associations between parity and incontinence in women over 50. The evidence is fairly consistent that the impact of parity on incontinence is not seen in geriatric populations. Given our results, it may be important for future studies to investigate the association between parity and incontinence severity, rather than the parameter of "any" incontinence.

Although this study has important strengths, including the large population-based sample, excellent response rates to questions, standardized evaluation of depression, and assessment of numerous confounders, certain limitations need to be considered. The incontinence question in the survey does not distinguish between urge and stress incontinence symptoms, and therefore risk factors that may differ between the two types cannot be evaluated. Although we were able to control for many potential and important confounders related to incontinence, this database had no information about some of the factors reported by others to be associated with incontinence, such as hysterectomy, constipation, or urinary tract infections. We were also unable to ascertain menopausal status; however, given that women were at least 50 years old, it is likely that the majority were postmenopausal. We have no information about the duration of incontinence or of prior or current treatment for incontinence. Although we have information about the number of children born to women in the study, we cannot consider the potential effects of childbirth practices. Our analytic strategy did not incorporate population weights; because certain groups were over-sampled, we cannot use these results to draw inference to the entire US population of women 50–69 years of age, but can only infer to the sample. Racial and ethnic groups were included as a covariate, and it is therefore unlikely that such over-sampling should affect the results of the regression analysis.

Finally, both incontinence and medical comorbidities were assessed by self-report. Although self-report combined with medical record information would be preferable, validity studies of self-report of chronic conditions have demonstrated acceptable agreement except for self-report of arthritis.^45,46 There is some variability of self-report of incontinence in older people (correlation .82 for incontinence questions issued 2 weeks apart).⁴⁷ It is not known whether this variability is similar in the middle-aged Health and Retirement Survey population, or whether women would fall into the same category of mild or severe incontinence on repeated questioning.

Our study highlights the importance of considering confounders when studying the relationship between depression and incontinence, and of choosing a depression measure that is more likely to reflect major depressive disorder rather than depressive symptoms. Despite the noncausal nature of our study, it remains of clinical importance to recognize the association between incontinence and depression. Although screening for depression is recommended for primary care visits, this may be overlooked for women seeking treatment for specific complaints, such as incontinence. This study confirms the importance of such screening.

	Footnotes

 
PII S0029-7844(02)02519-X

Received May 9, 2002. Received in revised form July 19, 2002. Accepted August 1, 2002.

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